CNSC ASPEN SELF STUDY QUESTIONS WITH CORRECT
ANSWERS
/. Modular products are used to enhance the nutrient profile of a feeding regimen. Which
of the following combinations represents modular products?
1. Safflower oil, protein, glucose and selenium
2. Glucose, glutamine, water and MCT oil
3. Protein, cholecalciferol, fiber and safflower oil
4. MCT oil, glucose, fiber and protein - Answer-✅4. MCT oil, glucose, fiber and protein
/.Protein powders, carbohydrate powders, fat emulsion, MCT oil, fiber and specific
amino acids are examples of what? - Answer-✅Modular products
/.Are vitamins, minerals and water considered modular products? - Answer-✅No
/.Early initiation of enteral feeding has been suggested to benefit ICU patients by
reducing infectious complications, length of hospital stay and even possibly reducing
mortality. Which group of patients might be at significant risk from early enteral feeding?
1. Cancer patients who underwent surgery of the GIT
2. Patients with increasing vasopressor support
3. TBI patients with intracranial pressure controlled by hypertonic saline
4. Patients admitted to the hospital with acute on chronic pancreatitis - Answer-✅2.
Patients with increasing vasopressor support
/.What is the risk of feeding a patient before hemodynamic stability has been achieved?
- Answer-✅May increase the risk of intestinal ischemia as blood perfusion of the gut
may be compromised in a patient who is still requiring high doses of vasopressor drugs
to maintain blood pressure
/.When should EN be initiated in the hemodynamically unstable patient? - Answer-✅EN
should be delayed until fluid resuscitation is complete
/.A patient with acute respiratory distress syndrome (ARDS) may benefit from a feeding
formula containing supplemental
1. arginine
2. glutamine
,3. nucleic acids
4. omega-3 fatty acids - Answer-✅4. omega-3 fatty acids
/.Define ARDS. - Answer-✅Acute respiratory distress syndrome - inflammatory
response leading to diffuse alveolar damage and lung capillary endothelial injury.
/.Why are formulas containing omega-3 fatty acids recommended in ALI and ARDS? -
Answer-✅Inflammatory mediators, including prostaglandins and leukotrienes derived
from arachidonic acid metabolism have been implicated in both ALI and ARDS.
Formulas containing omega-3 fatty acids may down regulate the inflammatory response
through the production of less inflammatory prostaglnadins and leukotrienes
/.What is the evidence for use of omega-3 fatty acids in ARDS and ALI? - Answer-
✅Based on 3 level 1 studies the Guidelines for the Provision and Assessment of
Nutrition Support Therapy in the Adult Critically Ill Patient in 2009 recommended
patients with ARDS and severe ALI be placed on an enteral formulation characterized
by an anti-inflammatory lipid profile. Subsequent to the publication of those guidelines
and recommendations have been studies published in 2011 showing that enteral
supplementation of omega-3 fatty acids did not result in improved biomarkers of
inflammation or clinical outcomes
/.The use of enteral nutrition formulas enriched with BCAAs is best used for patients
with:
1. cirrhosis
2. hepatic failure
3. liver transplantation
4. refractory encephalopathy - Answer-✅4. refractory encephalopathy
/.What is the theory behind use of BCAAs in hepatic encephalopathy? - Answer-
✅There is believed to be an increased ratio of aromatic amino acids to BCAAs in
patients experiencing hepatic encephalopathy. The decrease in BCAA is suspected to
be due to an increased breakdown in BCAA from skeletal muscles and utilization. The
increased levels of AAA generate false neurotransmitters, resulting in hepatic
encephalopathy symptoms.
/.What is the evidence for BCAA enriched amino acid enteral formulas? - Answer-
✅Published randomized trials have shown mixed results in patients with hepatic failure
receiving these specialized formulas. Due to the lack of evidence supporting their use
and the increased cost of such products it has been suggested that the use of these
hepatic fomulas be limited to patients with encephalopathy refractory to standard
medical therapy (lactulose, non-absorbed antibiotics)
/.Enteral nutrition may be contraindicated in the early post-transplant period in adult
patients with hematopoietic cell transplants because of:
,1. increased incidence of sinusitis with enteral feedings
2. lack of benefit from enteral feedings in allogeneic patients
3. gastrointestinal toxicities related to the conditioning regimen
4. improved survival seen in autologous patients receiving PN - Answer-✅3.
Gastrointestinal toxicities related to the conditioning regimen
/.Why is EN contraindicated in the early post-transplant period in adult patients with
hematopoietic cell transplants? - Answer-✅GI toxicities such as nausea, vomiting,
delayed gastric emptying and diarrhea seen in the first 2-3 weeks post-stem cell
transplant may preclude EN. GI toxicity is most often related to chemotherapy and total
body irradiatin, however GI toxicity may also result from other medications or early
acute graft-versus-host disease in this patient population.
/.Which nutrition therapy is preferred in early post-transplant hematopoietic cell
transplant patients (adult)? - Answer-✅Currently there is insufficient data to establish
benefits of enteral nutrition over parenteral nutrition with hematopoietic cell transplants.
In one study, parenteral nutrition was found to increase survival in allogeneic patients
/.Which of the following medications would be appropriate to crush and deliver via an
enteral feeding tube?
1. Nifedipine XL
2. Metoprolol immediate release
3. Enteric coated aspirin
4. Diltiazem CD - Answer-✅2. Metoprolol immediate release
/.What type of tablets should be crushed for administration via an enteral feeding tube?
- Answer-✅Only immediate release tablets should be crushed fro administration via an
enteral feeding tube.
/.Why are enteric coated and film coated tablets not crushed for administration via an
EN feeding tube? - Answer-✅Enteric coated or film coated tablets do not crush well and
tend to clump and increase the risk of clogging the tube.
/.Why are modified release dosage forms of drugs inappropriate to crush and give via
EN feeding tubes? - Answer-✅Modified release dosage forms (often designated with
abbreviations such as XL, XR, SR, CD etc.) are inappropriate to crush and give via EN
feeding tube because crushing these dosage forms destroys their modified releasing
properties. This may lead to an excessive dose of the drug being released at one time
(instead of slowly over a longer period of time), which can lead to adverse effects and
has even been reported as a cause of death
/.Which of the following describes an optimal method of preparing and administering
medications via an enteral feeding tube?
, 1. Crush tablets and add them directly in the EN formula
2. Administer liquid formulations undiluted to minimize fluid overload
3. Flush the tube with water before and after each medication administered
4. Add crushed tablets to liquid medication sand administer the mixture all together -
Answer-✅3. Flush the tube with water before and after each medication administered
/.Why should the EN tube be flushed before and after each medication? - Answer-
✅Helps to avoid physical interactions both between medications and between
medications and formula.
/.How should liquid formulations be administered? Why? - Answer-✅Many liquid
medications are hyperosmolar which can lead to diarrhea and/or have high viscosity
which can lead to tube clogging, so liquid dosage forms should be diluted with water
prior to administration
/.In patients with severe acute pancreatitis enteral nutrition has been documented to
provide the following benefits over parenteral nutrition EXCEPT:
1. decreased infection rate
2. decreased hospital LOS
3. decreased pain
4. decreased mortality - Answer-✅3. Decreased pain
/.List 5 benefits in patients with severe acute pancreatitis on EN vs. PN nutrition support
- Answer-✅1. significant reduction in infectious morbidity
2. decreased hospital LOS
3. Reduced need for surgical intervention
4. Reduced multiple organ failure
5. Decreased mortality
/.In patient with fat malabsorption, an enteral product containing which of the following
can provide a concentrated source of energy?
1. MCT
2. Free amino acids
3. Fructooligosaccharides
4. Long chain triglycerides - Answer-✅1. MCTs
/.What nutrient can be used to provide a concentrated source of energy to patients with
fat malabsorption or damage to lymphatic vessels? Why? - Answer-✅MCT
MCT are absorbed directly into the bloodstream and enter portal circulation bypassing
the need for pancreatic enzymes, bile, bile transport in the lymphatic system and
carnitine dependent transport into the mitochondria.
ANSWERS
/. Modular products are used to enhance the nutrient profile of a feeding regimen. Which
of the following combinations represents modular products?
1. Safflower oil, protein, glucose and selenium
2. Glucose, glutamine, water and MCT oil
3. Protein, cholecalciferol, fiber and safflower oil
4. MCT oil, glucose, fiber and protein - Answer-✅4. MCT oil, glucose, fiber and protein
/.Protein powders, carbohydrate powders, fat emulsion, MCT oil, fiber and specific
amino acids are examples of what? - Answer-✅Modular products
/.Are vitamins, minerals and water considered modular products? - Answer-✅No
/.Early initiation of enteral feeding has been suggested to benefit ICU patients by
reducing infectious complications, length of hospital stay and even possibly reducing
mortality. Which group of patients might be at significant risk from early enteral feeding?
1. Cancer patients who underwent surgery of the GIT
2. Patients with increasing vasopressor support
3. TBI patients with intracranial pressure controlled by hypertonic saline
4. Patients admitted to the hospital with acute on chronic pancreatitis - Answer-✅2.
Patients with increasing vasopressor support
/.What is the risk of feeding a patient before hemodynamic stability has been achieved?
- Answer-✅May increase the risk of intestinal ischemia as blood perfusion of the gut
may be compromised in a patient who is still requiring high doses of vasopressor drugs
to maintain blood pressure
/.When should EN be initiated in the hemodynamically unstable patient? - Answer-✅EN
should be delayed until fluid resuscitation is complete
/.A patient with acute respiratory distress syndrome (ARDS) may benefit from a feeding
formula containing supplemental
1. arginine
2. glutamine
,3. nucleic acids
4. omega-3 fatty acids - Answer-✅4. omega-3 fatty acids
/.Define ARDS. - Answer-✅Acute respiratory distress syndrome - inflammatory
response leading to diffuse alveolar damage and lung capillary endothelial injury.
/.Why are formulas containing omega-3 fatty acids recommended in ALI and ARDS? -
Answer-✅Inflammatory mediators, including prostaglandins and leukotrienes derived
from arachidonic acid metabolism have been implicated in both ALI and ARDS.
Formulas containing omega-3 fatty acids may down regulate the inflammatory response
through the production of less inflammatory prostaglnadins and leukotrienes
/.What is the evidence for use of omega-3 fatty acids in ARDS and ALI? - Answer-
✅Based on 3 level 1 studies the Guidelines for the Provision and Assessment of
Nutrition Support Therapy in the Adult Critically Ill Patient in 2009 recommended
patients with ARDS and severe ALI be placed on an enteral formulation characterized
by an anti-inflammatory lipid profile. Subsequent to the publication of those guidelines
and recommendations have been studies published in 2011 showing that enteral
supplementation of omega-3 fatty acids did not result in improved biomarkers of
inflammation or clinical outcomes
/.The use of enteral nutrition formulas enriched with BCAAs is best used for patients
with:
1. cirrhosis
2. hepatic failure
3. liver transplantation
4. refractory encephalopathy - Answer-✅4. refractory encephalopathy
/.What is the theory behind use of BCAAs in hepatic encephalopathy? - Answer-
✅There is believed to be an increased ratio of aromatic amino acids to BCAAs in
patients experiencing hepatic encephalopathy. The decrease in BCAA is suspected to
be due to an increased breakdown in BCAA from skeletal muscles and utilization. The
increased levels of AAA generate false neurotransmitters, resulting in hepatic
encephalopathy symptoms.
/.What is the evidence for BCAA enriched amino acid enteral formulas? - Answer-
✅Published randomized trials have shown mixed results in patients with hepatic failure
receiving these specialized formulas. Due to the lack of evidence supporting their use
and the increased cost of such products it has been suggested that the use of these
hepatic fomulas be limited to patients with encephalopathy refractory to standard
medical therapy (lactulose, non-absorbed antibiotics)
/.Enteral nutrition may be contraindicated in the early post-transplant period in adult
patients with hematopoietic cell transplants because of:
,1. increased incidence of sinusitis with enteral feedings
2. lack of benefit from enteral feedings in allogeneic patients
3. gastrointestinal toxicities related to the conditioning regimen
4. improved survival seen in autologous patients receiving PN - Answer-✅3.
Gastrointestinal toxicities related to the conditioning regimen
/.Why is EN contraindicated in the early post-transplant period in adult patients with
hematopoietic cell transplants? - Answer-✅GI toxicities such as nausea, vomiting,
delayed gastric emptying and diarrhea seen in the first 2-3 weeks post-stem cell
transplant may preclude EN. GI toxicity is most often related to chemotherapy and total
body irradiatin, however GI toxicity may also result from other medications or early
acute graft-versus-host disease in this patient population.
/.Which nutrition therapy is preferred in early post-transplant hematopoietic cell
transplant patients (adult)? - Answer-✅Currently there is insufficient data to establish
benefits of enteral nutrition over parenteral nutrition with hematopoietic cell transplants.
In one study, parenteral nutrition was found to increase survival in allogeneic patients
/.Which of the following medications would be appropriate to crush and deliver via an
enteral feeding tube?
1. Nifedipine XL
2. Metoprolol immediate release
3. Enteric coated aspirin
4. Diltiazem CD - Answer-✅2. Metoprolol immediate release
/.What type of tablets should be crushed for administration via an enteral feeding tube?
- Answer-✅Only immediate release tablets should be crushed fro administration via an
enteral feeding tube.
/.Why are enteric coated and film coated tablets not crushed for administration via an
EN feeding tube? - Answer-✅Enteric coated or film coated tablets do not crush well and
tend to clump and increase the risk of clogging the tube.
/.Why are modified release dosage forms of drugs inappropriate to crush and give via
EN feeding tubes? - Answer-✅Modified release dosage forms (often designated with
abbreviations such as XL, XR, SR, CD etc.) are inappropriate to crush and give via EN
feeding tube because crushing these dosage forms destroys their modified releasing
properties. This may lead to an excessive dose of the drug being released at one time
(instead of slowly over a longer period of time), which can lead to adverse effects and
has even been reported as a cause of death
/.Which of the following describes an optimal method of preparing and administering
medications via an enteral feeding tube?
, 1. Crush tablets and add them directly in the EN formula
2. Administer liquid formulations undiluted to minimize fluid overload
3. Flush the tube with water before and after each medication administered
4. Add crushed tablets to liquid medication sand administer the mixture all together -
Answer-✅3. Flush the tube with water before and after each medication administered
/.Why should the EN tube be flushed before and after each medication? - Answer-
✅Helps to avoid physical interactions both between medications and between
medications and formula.
/.How should liquid formulations be administered? Why? - Answer-✅Many liquid
medications are hyperosmolar which can lead to diarrhea and/or have high viscosity
which can lead to tube clogging, so liquid dosage forms should be diluted with water
prior to administration
/.In patients with severe acute pancreatitis enteral nutrition has been documented to
provide the following benefits over parenteral nutrition EXCEPT:
1. decreased infection rate
2. decreased hospital LOS
3. decreased pain
4. decreased mortality - Answer-✅3. Decreased pain
/.List 5 benefits in patients with severe acute pancreatitis on EN vs. PN nutrition support
- Answer-✅1. significant reduction in infectious morbidity
2. decreased hospital LOS
3. Reduced need for surgical intervention
4. Reduced multiple organ failure
5. Decreased mortality
/.In patient with fat malabsorption, an enteral product containing which of the following
can provide a concentrated source of energy?
1. MCT
2. Free amino acids
3. Fructooligosaccharides
4. Long chain triglycerides - Answer-✅1. MCTs
/.What nutrient can be used to provide a concentrated source of energy to patients with
fat malabsorption or damage to lymphatic vessels? Why? - Answer-✅MCT
MCT are absorbed directly into the bloodstream and enter portal circulation bypassing
the need for pancreatic enzymes, bile, bile transport in the lymphatic system and
carnitine dependent transport into the mitochondria.
